|Year : 2017 | Volume
| Issue : 1 | Page : 17-20
Silver cauterization: An office procedure for repair of small tympanic membrane perforation
Mohammad Waheed El-Anwar, Mohammad El-Sayed Abd Elbary, Ibrahim Mohammad Saber
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Web Publication||6-Feb-2017|
Mohammad Waheed El-Anwar
Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig
Source of Support: None, Conflict of Interest: None
Introduction: Patients with small tympanic membrane (TM) perforations often suffer from repeated infections rather than hearing loss. Repair of TM perforations is required regardless of its size, as without closure, morbidity may include hearing loss, chronic otorrhea, and cholesteatoma formation. Objective: To assess the effectiveness of the topical silver cauterization to refresh and close small TM perforation as an office-based procedure. Materials and Methods: Thirteen patients with small TM perforations were enrolled in the study. The margin of the perforation was cauterized using silver nitrate 10% that was repeated up to six times. The procedure was considered successful if there was no residual perforation within the follow-up period. Postoperative audiometry was performed before cauterization then at 3 months after. Results: Successful perforation repair was achieved in ten ears (76.9%). Mean hearing gain was 11.5 ± 8 for all cases and 15 ± 5.27 for succeeded cases. None of the patients developed infection, hearing impairment, tinnitus, vertigo, bleeding, taste disturbance, or hyperkeratosis. Conclusion: Office-based silver cautery is a safe, effective, and minimally invasive procedure. It is suitable for repairing small TM perforations with comparable success rate to conventional myringoplasty.
Keywords: Cautery, myringoplasty, silver, tympanic membrane
|How to cite this article:|
El-Anwar MW, Elbary ME, Saber IM. Silver cauterization: An office procedure for repair of small tympanic membrane perforation. Indian J Otol 2017;23:17-20
|How to cite this URL:|
El-Anwar MW, Elbary ME, Saber IM. Silver cauterization: An office procedure for repair of small tympanic membrane perforation. Indian J Otol [serial online] 2017 [cited 2017 Apr 28];23:17-20. Available from: http://www.indianjotol.org/text.asp?2017/23/1/17/199502
| Introduction|| |
Tympanic membrane (TM) has a significant role in the hearing physiology as well as in the pathophysiology of chronic inflammatory middle ear diseases. TM helps in sound waves transmission to sound conducting system of the middle ear; thus, any TM perforation can result in conductive deafness. Moreover, TM perforation can significantly impair the patient quality of life.
Therefore, repair of TM perforations is required regardless of its size to avoid morbidities such as hearing loss, chronic otorrhea, and cholesteatoma formation.
Many materials are available to be used during repair of the TM perforations such as perichondrium,, temporalis fascia, cartilage,, fat, and platelet-rich plasma (PRP).
Even though surgery has become the most common treatment, it has its drawbacks: because it is expensive, requires an anesthetic, is not always successful, and may have morbidity. It also occupies time on the surgery schedule that could be used for other procedures.
Chemical cautery was previously used by silver nitrate or trichloroacetic acid. The first recorded use of silver nitrate to stimulate closure of TM perforations was carried out by Wilde and Hewson in 1848. Derlacki reported a 75% closure rate in 1227 patients by average of >14 office settings. However, it was not regularly used.
The principle of chemical cauterization is that after application, it breaks up fibrosis and promotes granulation and new tissue formation at the margin of the perforation.
The aim of this study was to assess the effectiveness of the topical silver cauterization to refresh and close small TM perforation as an office-based procedure.
| Materials and Methods|| |
The study population included 26 patients who had a small dry TM perforation. TM perforation was considered small if it was <2 mm 2 or less than the size of half TM quadrant. The TM was divided into four quadrants as used by El-Anwar et al.
The TM perforation must be dry with apparently healthy middle ear mucosa for 1 month at least before surgery. Patients with TM perforations larger than half TM quadrant were excluded from the study. Patients with active ear discharge, cholesteatoma, marginal or attic perforations and those with suspected ossicular pathology having more than 40 dB air-bone gap (ABG) were also excluded from the study.
Written formal consent to participate in the study was signed by all the enrolled patients, and the study was approved by the Institutional Review Board.
All patients were subjected to full history taking, general and local examination, including otoscopic ear examination with audiological evaluation to ensure diagnosis and assess hearing level.
Patients were positioned in a sitting position with their face turned to the opposite side of the perforation. Under endoscopic control, the margin of the perforation was freshened by silver cautery through a transcanal approach using fine-tipped applicator dipped in 10% silver nitrate. Once the blanching of the rim was completed, a small sterile, gel foam was placed as a patch over the perforation. The principle of chemical cauterization is that after application, it breaks up fibrosis and promotes granulation and new tissue formation at the margin of the perforation. This silver cauterization was repeated at weekly intervals till closure of the perforation or maximum of six times. Neither ear dressing nor ear drops were used.
The patients were followed up at weekly intervals for 1 month and monthly for 3 months. The procedure was considered successful if there was no residual perforation within the follow-up period. Audiometry was repeated at 3-month postprocedure.
| Results|| |
Twenty-six patients, 16 females (61.54%) and 10 males (38.46%), who had small central TM perforation caused by tubotympanic chronic suppurative otitis media and fulfilled the selection and exclusion criteria were surgically repaired by silver cauterization from April 2013 to November 2015 at the Otorhinolaryngology Department. The perforation was in right TM in 14 patients (53.85) and in left TM in 12 patients (46.15%). The age of the patients ranged from 12 to 50 years with a mean of 28.6 ± 11.369 years. The mean preoperative ABG at speech frequencies was 21.9 ± 4.3 (range, 15–30) dB. Silver cautery was repeated between three and six times at weekly intervals with a mean of 4.46 ± 1.05.
Successful perforation repair was achieved in 20/26 (76.9%) ears. None of the patients developed infection, hearing impairment, tinnitus, vertigo, bleeding, taste disturbance, or hyperkeratosis. Postoperative mean ABG: 9.6 ± 8 (range, 0–25) dB, with significant improvement from preoperative value (t-test = 6.9054, P < 0.0001). Mean hearing gain was 11.5 ± 8 for all cases and 15 ± 5.27 for succeeded cases (range, 10–25). Noting that all cases got closed perforation achieved hearing gain by at least 10 dB [Table 1].
The mean duration of the procedures was 3 ± 1.6 min. All patients tolerated the procedure under topical anesthesia with no need to use an oral anxiolytic before the procedure or conscious sedation measures for the procedure itself. Postoperative pain was tolerable in all patients with no need for injectable analgesic.
| Discussion|| |
Patients with small TM perforations often suffer from repeated because of exposure of the ear to water during bathing or swimming or loss of “middle ear cushion” that facilitates Eustachian tube More Details reflux. Those patients seek myringoplasty to prevent these infections and expand their activities that are limited by water precautions.
Despite the safety and high success of myringoplasty, it carries some risks such as bleeding, infections, and possible ossicular chain injury. Furthermore, surgery is not accessible to all patients due to its costs and availability.
Because small TM perforations had a higher success rate than larger ones, more simple and less invasive techniques with less risk and cost are preferred. Three techniques are commonly used for repair of small TM perforations in the outpatient office setting; fat graft myringoplasty,, cauterization of the perforation margins, and paper patch myringoplasty.,, By fat graft myringoplasty, closure rates have been reported as 76%–92% of cases.,, On the other hand, closure rate by paper patching myringoplasty was 63.2%.
The principle of chemical cauterization is that it breaks up fibrosis and enhances granulation tissue formation and healing at the margin of the perforation. The patch acts as a splint to bridge the margins of the perforation. Given a flat surface, the epithelium grows at the rate of 1 mm/day.
It is believed that such procedure is painful to the patient and required infinite patience by the physician as well as the patient. However, in our study, the concentration of silver nitrate used was 10%, so pain was minimal that is why no local anesthesia was required resulting in minimizing the procedure time with no need for suction of the local anesthetic which may be implanted over the surface of the TM.
By cauterization method, some authors reported success in closing perforations in 75%–90% of cases. However, multiple treatment episodes that could reach 14 times were required.,, In the current study, transcanal silver cauterization was used achieving closure of the TM perforation 76.9% of cases after maximum six office sittings. This success rate is comparable to previous studies such as study by Debnath and Khanna (83.33%), study by Goldman (82.7%), study by Scaramella et al. (84.2%), and study by Uppal et al.(78%). On the other hand, Dunlop could get a 100% success, but he needed up to 33 treatment sessions.
In this study, the mean hearing gain was 11.5 ± 8 for all cases and 15 ± 5.27 for succeeded cases. While in Debnath and Khanna's study, the mean gain was 8.66 ± 3.69 dB.
Throughout the procedure, morbidity was minimized as there were no graft harvesting, no flap elevation, and no manipulation of middle ear structure. This resulted in abolishing donor site morbidity as hematomas, perichondritis, or auricular deformities and avoided possible injury to chorda tympani nerve or middle ear structures which can occur in conventional myringoplasty.
We did not use microscope making the procedure tools easily available and could be performed in every clinic. We used silver nitrate that readily available and cheap. Moreover, the use of 10% concentration and limiting maximum cauterization procedures to six times help to avoid risks of chemical damage such as pain, chemical burn of the middle ear mucosa and also middle ear infection  does not occur.
Mean of cauterization sets in the current study was 4.46 that is near to the studies of Santhi and Rajan  and Debnath and Khanna.
Similar to any office-based procedure, cauterization does not require general anesthesia or hospital admission. In addition, it has some advantages over the other common office-based procedures such as no incision for taking the graft as in fat myringoplasty.
However, like other office-based myringoplasty, exploration of the tympanic cavity could not be performed and the integrity and mobility of the ossicular chain could not be tested depending on preoperative data including audiometry.
Because of its substantial advantages, office-based silver cauterization could be considered an excellent safe primary modality for reconstruction of a small dry central TM perforation with equivalent success rate to existing surgical procedures, but it needs sequential multiple setting. Study on large series of patients and study of silver cauterization with PRP hourglass myringoplasty need to be studied.
| Conclusion|| |
Office-based silver cautery is a safe, effective, and minimally invasive procedure. It is suitable for repairing small TM perforations with comparable success rate to conventional myringoplasty.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Imamoglu M, Isik AU, Acuner O, Harova G, Bahadir O. Fat-plug and paper-patch myringoplasty in rats. J Otolaryngol 1998;27:318-21.
Tabb HG. Closure of perforations of the tympanic membrane by vein grafts. A preliminary report of twenty cases. Laryngoscope 1960;70:271-86.
El-Anwar MW, El-Ahl MA, Zidan AA, Yacoup MA. Topical use of autologous platelet rich plasma in myringoplasty. Auris Nasus Larynx 2015;42:365-8.
Storrs L. Myringoplasty with the use of fascia grafts. Arch Otolaryngol 1961;74:45-9.
Yetiser S, Tosun F, Satar B. Revision myringoplasty with solvent-dehydrated human dura mater (Tutoplast). Otolaryngol Head Neck Surg 2001;124:518-21.
Goldman NC. Chemical closure of chronic tympanic membrane perforations. ANZ J Surg 2007;77:850-1.
Wilde WR, Hewson A. Practical Observations on Aural Surgery and the Nature and Treatment of Diseases of the Ear. Philadelphia: Blanchard & Lea; 1853. p. 292-3.
Derlacki EL. Office closure of central tympanic membrane perforations: A quarter century of experience. Trans Am Acad Ophthalmol Otolaryngol 1973;77:53-66.
Marra S, Farrell BP, Kooiker PD, Marra S. Effectiveness of nonsurgical closure of tympanic membrane pars tensa perforation. Ear Nose Throat J 2002;81:556-8.
Saliba I. Hyaluronic acid fat graft myringoplasty: How we do it. Clin Otolaryngol 2008;33:610-4.
Maharjan M, Kafle P, Bista M, Shrestha S, Toran KC. Observation of hearing loss in patients with chronic suppurative otitis media tubotympanic type. Kathmandu Univ Med J (KUMJ) 2009;7:397-401.
Ozgursoy OB, Yorulmaz I. Fat graft myringoplasty: A cost-effective but underused procedure. J Laryngol Otol 2005;119:277-9.
Glasscock ME, Levine SC, McKennan KX. Tympanoplasty Implants. In: Paparella, Shumrick, Gluckman, Meyeroff, editors. Book chapter in Otolaryngology. Philadelphia, PA: Saunders; 1991. p. 1441-7.
Derlacki EL. Residual perforations after tympanoplasty: Office technique for closure. Otolaryngol Clin North Am 1982;15:861-7.
Golz A, Goldenberg D, Netzer A, Fradis M, Westerman ST, Westerman LM, et al.
Paper patching for chronic tympanic membrane perforations. Otolaryngol Head Neck Surg 2003;128:565-70.
Terry RM, Bellini MJ, Clayton MI, Gandhi AG. Fat graft myringoplasty – A prospective trial. Clin Otolaryngol Allied Sci 1988;13:227-9.
Konstantinidis I, Malliari H, Tsaki Ropoulou E, Constantinidis J. Fat myringoplasty as an office based procedure. Otorhinolaryngol Head Neck Surg 2010;42:25-8.
Santhi T, Rajan KV. A study of closure of tympanic membrane perforations by chemical cauterisation. Indian J Otolaryngol Head Neck Surg 2012;64:389-92.
Debnath M, Khanna S. A comparative study of closure of tympanic membrane perforation between chemical cauterization and fat plug myringoplasty. Int J Otolaryngol Head Neck Surg 2013;2:248-52.
Scaramella LF, Farrell BP, Kooiker PD, Marra S. Effectiveness of nonsurgical office closure of tympanic membrane pars tensa perforations. Ear Nose Throat J 2002;81:556-60.
Uppal KS, Singh R, Singh J, Popli SP. Closure of tympanic membrane perforations by chemical cautery. Indian J Otolaryngol Head Neck Surg 1997;49:151-3.